<!-- BEGIN: form -->
<table width="100%" cellpadding="3" cellspacing="0" border="0">
	<tr align="left">
		<td colspan="4" class="tdcartTitle"><strong>{LANG_CC_INFO_TITLE}</strong></td>
	</tr>
	<tr align="left">
		<td><strong>{LANG_FIRST_NAME}</strong></td>
	  <td><input type="text" name="dc_first_name" value="{VAL_FIRST_NAME}" class="textbox" /></td>
		<td><strong>{LANG_LAST_NAME}</strong></td>
	  <td><input type="text" name="dc_last_name" value="{VAL_LAST_NAME}" class="textbox" /></td>
	</tr>
	<tr align="left">
		<td><strong>{LANG_CARD_NUMBER}</strong>
	  <td colspan="3"><input type="text" name="dc_number" value="" size="16" maxlength="16" class="textbox" /></td>
	</tr>
	<tr align="left">
		<td><strong>{LANG_EXPIRES}</strong></td>
		<td colspan="3"><input type="text" name="dc_expiration_month" value="" size="2" maxlength="2" class="textbox" /> / <input type="text" name="dc_expiration_year" value="" size="2" maxlength="2" class="textbox" /> {LANG_MMYY}
  </tr>
	<tr align="left">
		<td><strong>{LANG_SECURITY_CODE}</strong>
	  <td colspan="3"><input type="text" name="dc_verification_number" value="" size="4" maxlength="4" class="textbox" /></td>
	</tr>
	<tr>
		<td colspan="4">&nbsp;</td>
	</tr>
	<tr align="left">
		<td colspan="4" class="tdcartTitle"><strong>{LANG_CUST_INFO_TITLE}</strong></td>
	</tr>				
	<tr align="left">
		<td><strong>{LANG_ADDRESS}</strong></td>
	  <td colspan="3"><input type="text" name="dc_address" value="{VAL_ADD_1}" size="50" class="textbox" /></td>
	</tr>
	<tr align="left">
		<td>
		<strong>{LANG_CITY}</strong> 
		</td>
		<td colspan="3">
		<input type="text" name="dc_city" value="{VAL_CITY}" class="textbox" />
	  </td>
  </tr>
		<tr align="left">
		<td>
		<strong>{LANG_STATE}</strong>
		</td>
		<td colspan="3">
		<input type="text" name="dc_state" value="{VAL_COUNTY}" size="2" class="textbox" />
		</td>
		</tr>
		<tr align="left">
		<td>
		<strong>{LANG_ZIPCODE}</strong>
		</td>
		<td colspan="3">
		<input type="text" name="dc_zipcode" value="{VAL_POST_CODE}" size="10" maxlength="10" class="textbox" />
	  </td>
	</tr>
	<tr align="left">
		<td><strong>{LANG_COUNTRY}</strong>
		<td colspan="3">
			<select name="dc_country" class="textbox">
				<!-- BEGIN: repeat_countries -->
				<option value="{VAL_COUNTRY_ISO}" {COUNTRY_SELECTED}>{VAL_COUNTRY_NAME}</option>
				<!-- END: repeat_countries -->
			</select>
	  </td>
	</tr>
</table>
<input type="hidden" name="gateway" value="PayJunction" />
<!-- END: form -->